Unspoken Debates – 1st Step to Recovery

Dysfunctional families sit down for dinner and dance around old feuds. They trip over unspoken debates and pray the kids don’t ask awkward questions.

The same thing happens in healthcare. Doctors sit down with patients and try not to think about why healthcare works the way it does.  Hopefully no one asks an awkward question.

How to Create a Mess – 101

In theory, healthcare works like this: Doctors care for patients and leave funding to the government. If patients need specific care that no one offers, some doctors retrain so that they can open clinics to provide the needed service.

Doctors fill needs and niches. They form an organic network of medical services and referral patterns around patient care.

Everything would work fine, if government could just let it happen and step in only when doctors and patients asked for help, for problems they cannot solve themselves.

Instead, government jumps in with its own ideas, even when no one asks. Government sets prices, designs programs for special interests and rations services for others.

Then, it tries to fix the ideas it just implemented.

After a few tries, government gets frustrated. It eventually takes command and builds what it wanted in the first place.

Obstructionist Doctors

Smart people in health bureaucracies often come up with plans that miss the point of care entirely. Without input from working physicians, designers draft plans built on ignorance or lopsided dogma.

If doctors point this out and challenge new ideas, they get labeled as obstructionist or divisive.

Wizened physician leaders lecture their ‘unprofessional’, obstructionist colleagues about relationships and collaboration. They remind us of the old days when they, too, used to fight government.

The wise ones would rather dismiss debate as inexperience or personality conflict, than address divergent opinion.

In a way, the wise ones are right. Government thickens wallets. Better to be close and rich, than principled and poor.

But ignoring differences and eschewing debate guarantees government does whatever it wants, as long as doctors get paid for it.

Start With Why

Why does healthcare look the way it does?

In part, care happens the way government wants. For example, the Ontario Liberal government gave themselves electronic access to private patient health records, with Bill 119. And they hope to completely redesign primary care, with Bill 210.

Government believes in centralized control and ignores all the times that command and control has failed in the last 100 years.

Doctors must ask:

Do they support the government’s vision for healthcare?

If so, why?

If not, why not?

Do doctors understand government’s vision?

Unspoken Debates

Ideological differences require discussion, research and promotion. Chatter about healthcare usually glosses over unspoken debates like:

• What are the limits, if any, to state involvement in care?
• Does professional autonomy generally benefit patients?
• Should we encourage or muzzle physician advocacy?
• What are the limits of regulation, if any, and how should we limit it?
• How does clinical judgment fit with clinical guidelines?
• How do different medical models impact the doctor-patient relationship?
• What approaches support innovation, creativity and excellence?
• How does patient service relate to quality?
• Where does patient individuality fit with standardized care?
• How does freedom of conscience impact care?
• Does personalized medicine trump guidelines?
• Can Medicine ever be controlled, if so, how?
  • And most importantly, How do all these questions impact patients?

Doctors cannot advance their own vision of healthcare unless they can answer these questions first.

This goes beyond policy. Health policy departments move from one policy issue to the next. They deliver positions as benchmarks. They do not function to keep debates alive by continually revisiting big ideas.

Anyone in a position to know enough to ask the really tough questions has too much to lose by asking them in public.

Anyone working inside the system – e.g., in a hospital or for government – cannot discuss dangerous ideas without compromising their position or funding.

Perhaps, medical associations should fund arm’s length think tanks to debate, develop and promote ideas?

Unspoken debates created the current mess in Ontario. Doctors need to look up from their patient charts and feel safe debating these dangerous questions. Its the first step to recovery.

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